A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit. 

Exhibits

Which of the following findings should the nurse report to the provider?.

Choice A rationale :

Contractions every 3 to 4 minutes. Rationale: Contractions are a significant sign of labor. When the uterus contracts regularly and with increasing intensity, it indicates that the woman is in labor. However, contractions alone may not be enough to confirm active labor, as Braxton Hicks contractions can occur earlier in pregnancy, which are often irregular and less intense.

Choice B rationale

Pain just above the navel. Rationale: Pain above the navel is not a specific indicator of labor. In late pregnancy, the baby's head may engage in the pelvis, causing pressure and discomfort in the upper abdomen. However, this symptom alone does not confirm active labor and can be attributed to various other factors as well.

Choice C rationale

Amniotic fluid in the vaginal vault. Rationale: The presence of amniotic fluid in the vaginal vault, also known as rupture of membranes or "water breaking,”. is a significant sign that labor is likely to be in progress or imminent. When the amniotic sac ruptures, it releases the fluid that surrounds the baby in the uterus. This is a clear indication of active labor.

Choice D rationale

Cervical dilation. Rationale: Cervical dilation is one of the most reliable signs of active labor. As the uterus contracts, the cervix starts to dilate and efface (thin out) to allow the baby's passage through the birth canal. Measuring cervical dilation during a pelvic examination provides valuable information about the progress of labor.

The correct answer is choice C. Assist the client to breathe into a paper bag.

Choice A rationale:

Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.

Choice B rationale:

Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.

Choice C rationale:

Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.

Choice D rationale:

Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.